Article Text

Download PDFPDF
Case series
Carotid cavernous fistula after Pipeline placement: a single-center experience and review of the literature
  1. Anil K Roy,
  2. Jonathan A Grossberg,
  3. Joshua W Osbun,
  4. Susana L Skukalek,
  5. Brian M Howard,
  6. Faiz U Ahmad,
  7. Frank Tong,
  8. Jacques E Dion,
  9. Charles M Cawley
  1. Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
  1. Correspondence to Dr Jonathan A Grossberg, Department of Neurosurgery, Emory University School of Medicine, 49 Jesse Hill Jr Dr, Room 337, Atlanta, GA 30303, USA; jonathan.a.grossberg{at}


Objective Carotid cavernous fistula (CCF) development after Pipeline Embolization Device (PED) treatment of cavernous carotid aneurysms (CCA) can be a challenging pathology to treat for the neurointerventionalist.

Methods A database of all patients whose aneurysms were treated with the PED since its approval by the Food and Drug Administration in 2011 was retrospectively reviewed. Demographic information, aneurysm characteristics, treatment technique, antiplatelet regimen, and follow-up data were collected. A literature review of all papers that describe PED treatment of CCA was then completed.

Results A total of 44 patients with 45 CCAs were identified (38 women, 6 men). The mean age was 59.9±9.0 years. The mean maximal aneurysm diameter was 15.9±6.9 mm (mean neck 7.1±3.6 mm). A single PED was deployed in 32 patients, with two PEDs deployed in 10 patients and three PEDs in 3 patients. Adjunctive coiling was performed in 3 patients. Mean follow-up duration based on final imaging (MR angiography or digital subtraction angiography) was 14.1±12.2 months. Five patients (11.4%) developed CCFs in the post-procedural period after PED treatment, all within 2 weeks of device placement. These CCFs were treated with a balloon test occlusion followed by parent artery sacrifice. Our literature review yielded only three reports of CCFs after PED placement, with the largest series having a CCF rate of 2.3%.

Conclusions CCF formation is a known risk of PED treatment of CCA. Although transvenous embolization can be used for treating CCFs, parent artery sacrifice remains a viable option on the basis of these data. Studies support the view that adjunctive coiling may have a protective effect against post-PED CCF formation. None of the coiled aneurysms in our database or in the literature have ruptured. Follow-up data will lead to a better understanding of the safety profile of the PED for CCA.

  • Aneurysm

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • AKR and JAG are co-first authors.

  • Contributors AKR conducted literature searches, drafted the initial version of the paper and revised the later versions. JAG conducted initial data collection, provided the initial idea for the study and revised the later versions of the paper. JWO assisted in selecting appropriate images and revision of the draft. SLS assisted in initial data collection and revision of the draft. BMH, FUA, and FT assisted in revision of the draft. JED assisted in literature searches and revision of the draft. CMC provided the initial idea of the study, monitored overall data collection and revision of the drafts.

  • Competing interests None declared.

  • Ethics approval Ethics approval was obtained from Emory University Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.